Book Review Essay: ‘Psyche on The Skin’ and ‘A History of Self-Harm in Britain’

Sarah Chaney and Chris Millard, in their respective volumes, ally themselves to a view of psychiatric knowledge that derives from historical epistemology. They both use Ian Hacking’s concept of ‘making up people’ to develop the ways that psychiatry produces specific objects of knowledge which are then transported to society through the expansion of psychiatric power - via psychiatric social workers, structures like the National Health Service (NHS) in the UK, and education programmes. The increased prevalence of the self-harmer is in part produced by the sustained and expanding psychiatric attention.

Sarah Chaney, Psyche on the Skin, Reaktion Books, London, 2017, £20.00, 320pp. ISBN 9781780237503;

Chris Millard, A History of Self-Harm in Britain: a genealogy of cutting and overdosing, Palgrave, London, 2015, £15.99 and available open access. ISBN  9781137547736.

by Ivan Crozier

People have always changed their bodies in permanent ways – whether with tattoos, scars, tongue splits, brands, piercings, genital modifications (from religious circumcision to self-bifurcation), or through cosmetic surgery. These changes give the body a particular meaning that is entirely dependent on the social context. Sometimes, scarification is done to show belonging to a particular ethnic group (a Mossi man from Burkina Faso was traditionally initiated with specific facial scars made with a hot knife), while other scars might be consensually produced as a part of a heavy sadomasochistic scene, and yet others – as these two books show – might be the result of a distressed teenager engaging in a self-harming practice which increasingly became viewed as a ‘cry for help’ within psychiatric discourses, and which necessitated the intervention of mental health professionals. These acts of body modification only take on their meanings within certain social groups. In some cases, self-injury is framed as resulting from a disturbed mind. Psychiatry is the dominant current way of understanding deliberate self-inflicted injuries in the west, but this was not always the framework, and, as these two books show, there is much to suggest that psychiatric power is being resisted in current corporeal practices.

The abhorrence that has framed self-injuring is partly tied up in ideas about pain as a wholly negative experience, with those willing to engage in it consciously believed to be mentally disturbed and requiring psychiatric attention. This is the main reason that sadomasochistic practices come under the scrutiny of psychiatrists. Another important framework for considering self-harm is the social and legal status granted to suicide. Self-harm was developed as a category within psychiatry, firstly believed to be ‘failed suicide,’ and then ‘para-suicide,’ before becoming a different category altogether (Non-Suicidal Self-Injury, as it is in the  of fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5), where it made its first appearance as a self-contained condition in 2013). The links between the legal and medical status of self-harm created the conditions whereby psychiatry could develop a theoretical apparatus for constructing a new category, although other social factors also shaped the way psychiatrists’ thought about self-harm. For example, self harm was increasingly gendered as feminine. This was because it was seen to be the result of domestic distress, where sometimes women hurt themselves to guilt their partners into not leaving them. This gendered conception of self-harm is still seen today, with American psychiatric research showing that adolescent females are the most typical group to cut themselves. What acts of self-injury mean depends very much on how they are understood by the different psychiatric discourses that have attended to them, as well as by the people who commit them.

Sarah Chaney and Chris Millard, in their respective volumes, ally themselves to a view of psychiatric knowledge that derives from historical epistemology. They both use Ian Hacking’s concept of ‘making up people’ to develop the ways that psychiatry produces specific objects of knowledge which are then transported to society through the expansion of psychiatric power – via psychiatric social workers, structures like the National Health Service (NHS) in the UK, and education programmes. The increased prevalence of the self-harmer is in part produced by the sustained and expanding psychiatric attention. By adopting this historical-epistemological standpoint, both books show that self-harm is ‘transient’ in Hacking’s sense; that it is not a stable category, but one which changes over the course of the history of psychiatry: the teenage girls who cut themselves, and discuss what this means to them, on the internet today are not the same as the women in the 1960s who poisoned themselves so their boyfriends wouldn’t leave, even though psychiatry has placed them both in the category of self-harm. How Chaney and Millard develop this analytic framework is not identical, but rather illustrates two different modes of medical historiography: (1) a macro, longue durée approach with an engaging narrative that bears some of the hallmarks of Roy Porter’s influence (Chaney); (2) an extremely detailed micro-history of the development of the concepts of self-harm within the context of British psychiatry, but with close attention to the sites where new psychiatric practices developed (such as the Edinburgh Royal Infirmary and the Institute of Psychiatry in London) and which owes much more to the historical Sociology of Scientific Knowledge as applied to medical practices (Millard). Both books problematize psychiatric knowledge, and seek explanations for the shape that it took by looking at the social and conceptual frameworks in which this knowledge was developed, with the resulting works being very different, yet complimentary.

Sarah Chaney’s fantastically illustrated Psyche on the Skin is written for a popular audience and anyone with a personal or professional interest in the subject will be well-rewarded by her book. Chaney uses history to refute the idea that self-inflicted injuries have a universal meaning by showing a variety of episodes where individuals hurt themselves, but were not considered to be episodes of self-harm in a modern psychiatric sense. She discusses practices such as blood-letting, where cutting the self was considered to yield positive results, and castration, which some believed to be beneficial (in particular members of the Skoptsy sect in Russia). Such practices have existed since the ancient world, without any speculation about the individual’s mental health. Chaney’s main focus, and her best research, is on the Victorian period. Using hospital records from Bethlem, as well as a thorough examination of existing medical literature, Chaney shows that self-mutilation was relatively common among the mentally ill in the Victorian period (with 11% of the Bethlem patient population hurting themselves between 1880-1900, employing methods such as burning, biting, plucking, cutting, castration and ocular enucleation). In these instances, self-harming was considered to exemplify the ‘morbid instinct’ that characterised insanity in this period. Self-harm was not a psychiatric object in itself, but was a manifestation of insanity. Self-mutilation, like suicide, was considered an unnatural practice by Victorian psychiatrists (or alienists, as they were typically known in this period) because it was not perceived to benefit the patient. Sexual self-mutilation was addressed as a part of the increased attention to sexuality seen in Victorian and Edwardian medicine.  Practices such as masturbation were seen as self-harming, because of the assumed deleterious effects, and a number of the patients whose records Chaney examined spoke of wishing to be castrated in order to prevent this vice (interestingly, some others wished for castration as a form of gender reassignment).

Other instances of self-harm were associated with hysteria, including the practice of piercing oneself with sewing needles (by 1897 there were enough cases of this practice reported in the medical literature for the women who regularly pierced themselves to be given the name of ‘needle girls’). Particular traits, such as deceit, came to be associated with self-harm, because efforts were made to conceal self-injury and the motivations behind it – and this association apparently remains today. Sometimes the reported self-harm practices were of a sexual nature, such as the insertion of hairpins into the urethra – which, although considered to be a form of self-mutilation by physicians at the time, may have been the result of poorly executed urethral masturbation (urethral sounding).  Chaney’s survey of the literature on self-harm attends to the psychoanalytic writing on the topic, including a long discussion of Karl Menninger’s Man Against Himself (1938) She also discusses the changes in later psychiatric theories of self-harm, from re-writing it as a practice associated with Borderline Personality Disorder and Post-Traumatic Stress Disorder, to an analysis of Armando Favazza’s Bodies Under Seige (1987). The latter utilised cultural-psychiatric approaches to looking at self-harm relativistically, and suggested that – contrary to much preceding psychiatry – self-harm was often an attempt at self-healing, by taking control of the body in a deliberate way, focusing, and submitting to the pain and then the relaxed feelings that followed such activity. Pain is typically considered negative in the Western imagination, but there are many instances where submitting to pain can bring positive results.

Chaney does not limit her work to psychiatric discourses alone, but provides a welcome analysis of some literary and other artistic depictions of self-harm, giving non-psychiatric voices a legitimate place in her study. Finally, and very importantly, Chaney examines the role played by the popular press and especially the internet in the culture of self-harm – both as a place where information about self-harm could circulate, both from ‘official’ health-care sources, and in patient-led ‘survivor group’ discussions. These non-psychiatric sources are an important part of the ‘making up’ of self-harm. Chaney’s work is both broad and rich and is written in an engaging way that will make this book a valuable resource for anyone trying to understand self-harm practices outside of the narrow confines of psychiatric discourses.

Chris Millard’s A History of Self-Harm in Britain is exhaustive in its genealogical approach to the concepts of self-harm in Britain, and as such is an exemplary case study in the sociological reconstruction of psychiatric knowledge. Most importantly, although he relies heavily on published British medical sources and theses (and it appears that he did not miss a single work), Millard does not fail to examine the practices that allowed for the development of these concepts. He shows how self-harm first emerged as a psychiatric problem by looking at how ‘failed suicide’ attempts (through traumatic injury as well as self-poisoning) in the 1910s and 1920s led to the injured person being taken to voluntary hospitals and workhouse infirmaries, in order to deal with the self-inflicted harm; after the 1930 Mental Treatment Act, which saw mental health becoming more integrated into general medical practices, these ‘failed suicides’ were able to be assessed more readily by psychiatrists. This situation was further stimulated by changes in the law regarding suicide (it was decriminalised in the UK in 1961), which Millard shows led to the integration of therapeutic regimes, joining the somatic approach of casualty departments to acute psychiatric care for the damaged person. The NHS further expanded the remit of psychiatry (especially via psychiatric social workers) into the homes of self-harmers, where a detailed picture began to emerge about the kinds of people who hurt themselves and their motivations for so doing. These practices of observation, which Millard examines in particular detail by assessing the role of the Observation Ward at Edinburgh, led to a psychiatric intervention into what had been a problem within physical medicine (the ‘failed suicide’ became a psychiatric category that could be followed home once their health returned for further investigation). Psychiatric explanations began to be offered to explain why the person had done such violence to themselves. A complex picture emerged whereby self-harm (especially overdosing) was considered to be a cry for help rather than a genuine attempt to end a life. By focusing on the changing practices within psychiatric care, Millard offers a compelling explanation for the development of this new psychiatric category, rather than just following its emergence through the pages of the Journal of Mental Science. Although in Britain the main focus for this argument was on self-poisoning (which makes up the largest number of hospitalizations for self-harm), increasingly under the influence of American psychiatry, it is self-cutting that has come to embody the exemplar of the contemporary self-harmer.

Millard is at his most remarkable in his conclusion, where he expands his argument in brilliant fashion to discuss the movement of self-harm from a communicative indication of internal suffering to an individualised, neurological issue by mapping these changes in psychiatry onto the ideological changes that followed the demise of social ideals to an embrace of neoliberal ideologies. He writes:

‘This political shift broadly coincides and intimately corresponds to the much more individualistic reading of self-damage, based on emotional self-regulation.  Indeed, neo-liberalism’s stress on individual actor’s radical freedom to make choices for their own benefit fits well with a model of self-harm that emphasises the individualistic, private feelings of tension, and the regulation of these through cutting. The coincidence of neo-liberal political ascendency from the early 1980s in the United States and United Kingdom, and the displacement of the social setting from understandings of self-damage are not chance occurrences.’ (205)

Self-harm is one of many examples where psychiatric care has moved to emphasise individuals, who can be put on medication regimes, rather than the more communal view of mental health and community therapy that flourished between the 1950s and 1970s.

Sometimes the detail in both books could have been significantly lessened.  To pick two examples, Chaney’s discussion of Freud’s Wolfman, and Millard’s 6 page exegesis of Samuel Waldenberg’s MPhil thesis on wrist-cutting, could have both have been much shorter without losing any significance to the respective books; this is probably an artefact of the two books having been converted out of PhDs. Furthermore given the foucaultien framework that was developed by Ian Hacking and which has influenced these two authors, it was a little surprising that more was not said about resistance. Sarah Chaney does end her book by looking at the ways that some self-harmers have responded to their condition, by taking back their lives from the medical practices in which they were framed as self-harming, through the production of literary, artistic and even historical works. On the other hand, Millard’s book gives little sense that any of the sufferers were anything other than passive actors in a complex medical system – which sits a little uncomfortably with his critique of neo-liberalism, which may even encourage such radical self-determination. It would have been very interesting to think even more broadly about the ways that self-harmers actively resist these medical discourses – as can be seen, for example, on the kinds of internet discussion forums on self-harm (as examined by Helena Mattingley’s 2009 Edinburgh University MSc thesis on self-harm). The making up of people is – as Hacking realised – not simply a top-down process. Individuals sometimes respond directly to these psychiatric regimes, and have otherwise developed their own strategies to cope with their struggles.  Often, taking control of their own body –by cutting it, or via some of the many other bodily practices that are increasingly prevalent, such as tattooing, sadomasochism, or other extreme bodily practices – is often seen to give a sense of asserted autonomy in a world where people increasingly are regulated. Placing the self-harmers in relation to these other bodily practices would help break them out of the psychiatric framework in which they have been confined.  The body can be a site for resistance, as well as a frame for the deployment of power.

I strongly recommend these two books for anyone interested in the topic of self-harm. They show two faces of the history of psychiatry as it is currently emerging from the University of London, and should be widely read.

Ivan Crozier is an Associate Professor and ARC Future Fellow in the History Department, of The University of Sydney, Australia